Gust Stephen Stringos, DO, FAAFP, FASAM, Medical Director Redington Fairview General Hospital (RFGH) and Medical Director RFGH Bridge Clinic for Opioid Use Disorder
As a practicing family physician for many years, what led you to obtain your x-waiver and addiction medicine certification?
I have always been interested in substance misuse and addiction in my general adult medicine practice. For the first decades of my practice, that was primarily alcohol. I never thought narcotics addiction would be an issue in Skowhegan, Maine, or central Maine. After a sabbatical in 2005, I returned and became a medical examiner, and at that point, I became more aware that overdoses and fatal overdoses were happening in Somerset County. But I still thought of it as a rare, unusual occurrence and not something that affected our general community until a patient of mine came in and told me that she had a problem with opioid dependence and wanted help. She asked me to treat her. I said, “Well, I don’t do that.” And she said, “Well, why not?” That stimulated me to reflect, “Why aren’t I doing this for a patient who requested it?” However, I sent that patient to another person who was the only person in our community at that point who was offering buprenorphine prescribing. That was a turning point and stimulated me to learn about it and to get my x-waiver. Responding to the need, I started seeing patients, and more and more patients came. This was different as I had never had patients knocking on my door asking for treatment for diabetes and heart disease, which is what I did with most of my time as a practitioner.
What were some challenges to increasing access to medication for opioid use disorder services in Somerset County?
At that point, there were two or three, eventually, maybe four of us doing opioid use disorder treatment in Somerset County. Still, we were all in our own silos and unconnected to each other, to the mental health system, the ER, or the hospital. Eventually, we all realized this was a problem.
Another challenge was that there was a lot of stigmas associated with treatment, not only for the patient with opioid dependence but for the providers. Comments like, “Why are you doing that?” with vague implications that this was illegal. If you met another doctor and said you were offering addiction treatment, they’d say, “Oh,” and then move away from you. That was a problem. It was a big problem for patients because if they went to the ER or got admitted to the hospital for some reason, they were treated terribly, and their main issue, the opioid use disorder, wasn’t addressed. If it was addressed, it was done in a very shaming kind of way.
How did you get started in addressing the problem through the system?
In 2018 we started the needed hospital-wide training on opioid use disorder to raise their awareness of the problem, not necessarily to get them to prescribe. That was the kickoff to many years of work getting people trained, reducing stigma, and, most importantly, reaching out to the community because the hospital alone can’t do the work without community behavioral health agencies, the police, schools, and the community in general. Along with a whole task force for Somerset County, we got everyone involved — the pharmacies, the police, the mental health services, and the medical providers.
How did you continue and expand your work?
It was one step leading to the next step, knowing that you couldn’t do it alone. That perspective is critical. We started very small and didn’t try to develop a grand program all at once. But, through that initial presentation, a few more people got their x-waivers. So now we had more of a group that could take on patients. The next big step was that we identified that rapid treatment access was needed.
We started what we called the Bridge Clinic, which meant that a person could present to the emergency room any hour of the day or night, and the ER providers would be able to start the person on buprenorphine and continue that treatment for some days until a very rapid warm handoff to one of the x-waivered providers to see the patient in the office for basically a short-term stabilization. That was a big step. Everyone feared we would be inundated with patients, but that wasn’t the case. It was more of a slow, steady trickle. In the end, the ER providers were pleased with this because previously they felt helpless when someone presented after an overdose saying, “I want help,” and all they could do was give the person a card and say, “Call this number, and maybe someone will get back to you in a week or two.”
There is no easy path to treatment. That’s very frustrating for providers, who feel they don’t have anything to offer. So now, with the Bridge Clinic, they could do something and help the patient. Likewise, with our police officers in town, if they encountered someone who wanted or needed help, they knew they had quick and easy access to treatment.
We developed this service in the hospital. The hospitalists knew how to treat cellulitis and endocarditis but weren’t comfortable prescribing buprenorphine or knowing what to do when a patient was discharged. With the Bridge Clinic, we were able to provide inpatient consultations on opioid use disorder and then have a plan for the patient to continue medication after discharge. The hospitalists were very happy with this. We then needed to help with long-term treatment, especially for patients with co-occurring disorders. To that end, we did a lot of work with folks at Kennebec Behavioral Health who were interested in starting an opioid health home to treat addiction, which is now established. It was building out and seeing what was needed to address the gaps. People started feeling empowered. If they knew the resources were there, they would be more willing to act on their piece of that pie.
Do you have any advice for other prescribers or practices you would like to share?
What was helpful for us was that we did everything in small, gradual steps. We never mandated primary care to do this. We let people get on board at their own pace and kept a positive message going all the time. We built opportunities for ongoing education into the system, but without mandates.
Why do this at all as a busy primary care provider?
From my perspective, I can say it’s the most gratifying work that I’ve done. It’s a real public health emergency. Treatment is evolving. So it’s an exciting field to be involved with, and it’s the only part of medical practice where I’ve seen patients’ lives transform, going from being in a horrible, terrible place to being a happy, productive, functioning member of society. I don’t get an opportunity to do that in the rest of my practice. Some people go from poorly controlled diabetics to well-controlled diabetics, but their lives are not profoundly changed as they are with the treatment of opioid use disorder. Treatment of opioid use disorders affects the patient’s children, spouses, extended family, and employers. It’s very gratifying when you have success, which doesn’t always happen. But more often than not it does, the treatment does work. The stigma and fear are offset by your experience of finding that this work is highly gratifying and helpful for the patient, the extended family, and the community.
How did you get all primary care providers to obtain their x-waivers at Redington-Fairview General Hospital (RFGH)?
I was very surprised when I found this out. People just did it. This doesn’t mean they’re all doing Medication Assisted Treatment (MAT or MOUD), but they’ve at least gotten their waiver, which is a huge first step. Some people are very early in using their x-waiver, and other providers are gradually increasing their comfort levels. A good model I’ve tried to use is to take on other providers’ patients, get them stable, and say to the provider, “Your patient is doing well, and why don’t you take them over again?” That has been a good way of getting people comfortable with the process. Again, we’re just at the beginning of this and still have a long, long way to go. It is a nice milestone to say we have accomplished this.
What has kept you practicing rural Maine?
It’s just a great place to live. I like outdoor activities, gardening, beekeeping, and things that lend themselves to rural living. I was very attracted to this in the ’70s. We have a handful of young, new doctors, so a few like the same thing. It can be a hard sell — work hard, probably earn less, less support. What’s not to love about that? But it’s a great place to live. You develop wonderful relationships with patients and the community. It’s a great place to raise a family. We do have good supportive relationships here. You feel that you’re needed and wanted, which is nice. Probably, Portland doesn’t need another doctor or two, but Central Maine does, and people appreciate those who come.
Any comments for small rural hospitals trying to develop a system to offer medication for opioid use disorder?
Just start where you are. Take inventory of your resources and build things one step at a time. These aren’t problems that we can solve with huge infusions of money. Money helps, of course, and the support from the state government certainly has been a huge help with supportive policies. Grants are a help. But don’t rely on those things; start where you are and take it one step and one patient at a time, and the system will slowly build itself to the appropriate level.